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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address al� E�(/ Q.L��' _ City Lot Size PM Owner's Name � fyl yl /�'l 8&W 0 Address r � / 1 0 hone Contractor— Address l ,` L I n`/ License No. 2/1sZ Phone66 0�t TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION j�❑ SYSTEM REPAIR ❑ OTHER ❑' DISTANCE TO NEAREST: SEPTIC TANK _L_ SEWER LINES DISPOSAL FLD.r�� PROP. LENS /0'4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATJONS for ❑ dustrial ❑ pen Bottom ❑ Manteca Dia. of Well Excava ' n Dia. of Well.Casing nn Domestic/Private ravel Pack cy Type of Casing ci� C- Specifications 166' f f"I Public 1-1 Other /nDelta Depth of Grout Seal 10W Type of Grout�S% ,�. I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by47&1!2lAl� _ Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of.bedrooms Character of soil to a depth of 3 feet: I Water table depth G SEPTIC TANK ❑ Type/Mfgt Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal y Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I 1 Depth Size _ Number J SUMPS 0 Distance to nearest: Well Foundation Property Line Q DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules-and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." } The applicant Zmu :;;;a:1111 �allre ire irictions. Complete drawing on revy+ side. � _ Signed X Title: �f bate: Y v/�( —a FOR DEPARTMENT USE ONLY Application Accepted by 7TI Date /0 Area Pit or Grout Inspection by Date Final Inspection by to Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-710e ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F FEE INFO AMOUNT DUE f AMOUNT REMITTED ASH RECEIVED BY DATEL� //�'�� PERMIT'NO. +.EH 13-24(REV.i i A5) �, ` +�( —1 EH 14-26 1 +IJ 1 /